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Author Notes:

PAS 2020 Conference cancelled due to Covid-19 pandemic.

Subject:

Keywords:

  • intravenous fluids
  • children and adolescents
  • emergency department
  • Hypotonic IVFs
  • standard of care
  • hyponatremia
  • isotonic maintenance IVFs
  • clinical practice guideline
  • potassium chloride
  • dextrose

Standardizing Use of Isotonic Maintenance Intravenous Fluids in the Emergency Department (ED) – A Quality Improvement (QI) Initiative

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Proceedings Title:

PAS Conference

Conference Name:

Pediatric Academic Society

Conference Place:

PA

Publication Date:

Type of Work:

Conference | Post-print: After Peer Review

Abstract:

Introduction Maintenance intravenous fluids (IVFs) are commonly used in children in the hospital setting, including in the Emergency Department (ED). Hypotonic IVFs have been the standard of care in pediatrics, but concerns about the high incidence of hyponatremia have been raised. Our institution had already been discussing switching to isotonic maintenance IVFs when the American Academy of Pediatrics (AAP) released a clinical practice guideline (CPG) in December 2018. The AAP CPG recommends patients 28 days to 18 years of age requiring maintenance IVFs receive isotonic solutions with appropriate potassium chloride (KCl) and dextrose. Objective In ED patients who are being admitted with maintenance IVFs to the inpatient ward, we aimed to increase use of isotonic fluids to >80% by Dec 2019. Methods Setting: 3 pediatric EDs in a large tertiary care pediatric healthcare system. A review of patients who had maintenance fluids ordered (defined as D5NS, D51/2NS, D51/4NS (each with or without KCl) at a rate of >10 ml/hr) prior to and after a QI intervention was performed. QI interventions included (1) institutional discussions on use of isotonic maintenance IVFs based on literature review, (2) education on isotonic maintenance fluids in accordance with the AAP CPG, (3) electronic medical record (EPIC) changes to encourage use of isotonic maintenance IVFs, (4) group practice review and individual feedback to outlier providers on their isotonic IVF use. Balancing measures included monitoring for increased frequency of serum electrolyte check within 24 hours of admission from the ED and incidence of hypernatremia. Data were analyzed using a run chart with Jan-Nov 2018 as baseline. Results Between Jan 2018 and Dec 2019, a mean of 115 patients/month meeting inclusion criteria had maintenance fluids ordered. The annotated run chart depicts isotonic fluid use over time. Centerlines were recalculated using accepted rules for differentiating common vs. special cause variation. By September of 2019, 80% of children received isotonic fluids, but more data points are needed to determine if this increase represents another sustained special cause variation. Measurement of performance on balancing measures is ongoing. Conclusion We were able to quickly increase use of isotonic maintenance fluids in ED patients being admitted to the inpatient setting. This rapid implementation of AAP recommendations may have been successful in part because of institutional readiness for change at the time the CPG was released. Additionally, hardwiring the preferred fluids via electronic medical record changes was a key intervention.

Copyright information:

The authors 2020

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